Mental Health and Substance Use Disorder Functional Screen Instructions: Module 3 - Community Living Skills Inventory

Download the complete Mental Health and Substance Use Disorder Instruction Manual and Best Practices, P-00934 (PDF).

3.1 Introduction

Need for assistance defined
Eligibility for services is based on an applicant’s need for assistance. Need for assistance is any kind of support from another person (monitoring, supervising, reminders, verbal cueing, or hands-on assistance) needed because of a mental health and/or substance use disorder. When someone has complex needs, it is difficult, if not impossible, to separate the reasons for their functional impairments. For such individuals, mark help needed in community living skills in the screen. If the person has mental illness and/or substance use as well, they could be eligible for long-term care and mental health and substance use disorder programs. If a person has only dementia, they should be referred for a long-term care functional screen.

General guidelines for answer selections

• Always select the answer that most closely describes the person’s need for help from another person no matter if they are receiving help.
• Always select only one rating of help needed with each activity.
• Each skill has its own definition purposefully constructed for the screen. Screeners must follow the definitions listed in this document to select the most accurate rating for level of help needed.
• Indicate the amount of help the person needs from another person no matter who is providing the help and no matter where. (When a person is to be discharged from a facility within a few days, estimate what they'll need in their new setting.)
• If a person can complete a task independently, but it takes them a very long time, consider if the person needs any help with that task to complete it safely and without negative outcomes. If they are in fact completing tasks safely, it does not matter if it takes two or three times longer than for most people. However, if there were significant hardships or negative outcomes for the person doing the task so slowly, it would be justified to mark the person as needing help.
• In the screen, basic means adequate for health and safety.
• Needs and safety should not be over interpreted. The screen is intended to be an objective review of a person’s need for assistance. Thus, ask: “Would a screener with a different professional background, gender, culture, etc., rank the person the same way?” (See Section 1.8 for more information relating to inter-rater reliability.)
• If the applicant needs help due to a physical impairment from a disability or impacts of aging, do not check community living skills in the screen. Such needs are to be indicated only in the last item in this module, physical assistance.
• Do not check assistance needed if the assistance is due only to cultural or language differences.
• Do not check help needed for money management and basic nutrition if all the person needs is transportation to the bank or stores. The transportation issue is captured in the transportation question.
• Because the definition specifically mentions support from another person, the need for assistance does not include support through self-help programs, medication, monetary resources, or medical equipment.

Frequency of help needed
The frequency of need for assistance checked on the screen should reflect actual needs as closely as possible. Help includes support provided through talks, reminders, monitoring, and supervision provided by family, friends, and/or paid staff. Example: If the family provides medication reminders every day, daily assistance is the frequent of help needed from others.

The frequency of help needed options in the screen vary by question.

Do not check a frequency based on what the applicant says they need or don’t need. The screener’s opinion should not factor into the decision on what frequency to check. Check the frequency that most screeners would agree should be in the service or treatment plan for the applicant.

If the applicant verbally denies the help, but accepts the help, check the appropriate box for the frequency of need for assistance for that item. This would include visits to monitor, cue, or negotiate.

If an applicant denies the need for assistance and will not allow assistance to be provided, answer the questions based on what the applicant could benefit from. Check the appropriate box for frequency of need for assistance for that item based on the screener’s understanding of the person’s needs during the screening process. The screen is intended to indicate what the person needs, even if they refuse the help. An individualized service plan is negotiated with the applicant, but the screen looks specifically for needs.

If the applicant is a current consumer of mental health and substance use disorder services, frequencies selected will usually match frequencies of practitioner contacts with the individual. In this way, completing the screen is like developing the applicant’s individualized service plan.

Check the appropriate box for frequency of need for assistance for an item based on the applicant’s need, not the capacity of the screener agency to provide help to the applicant.

If the applicant shares that they receive help from natural supports, such as family or friends, then check the appropriate box for the frequency of need for assistance for that item. The screen is meant to capture assistance provided from anyone in the applicant’s life, including their natural supports.

Selecting a frequency of help needed can be difficult because the applicant’s needs may not be obvious. Their needs may vary because of the cyclical nature of mental illness and substance use disorders. Mental health and substance use disorder providers have always had to estimate frequency of help needed based on limited information when developing an initial service plan for a consumer. Use the same professional judgement in this section of the screen.

Ranking fluctuating needs
Mental illnesses and substance use disorders are often cyclical, with varying levels of symptoms and functioning. The screen is not merely a snapshot of the present moment, but an averaging over longer periods from several months up to three years dependent upon the section. Every day mental health and substance use disorder practitioners make judgments based on this mix of point in time and historical views to determine the frequency of contacts from the current point in time up to the next few weeks or months. People’s needs will change. Predictions are only approximate. However, these need determinations reflect expert judgment and sometimes research data of the frequency of interventions needed to promote recovery and prevent crises.

For some community living skills, the choices include:

• Independent: The applicant does not require assistance with tasks. They can complete a task, support themselves emotionally, and monitor symptoms without interventions from support staff or natural supports.
• Less than monthly: The applicant requires assistance with tasks, emotional support, reinforcement, and symptom monitoring from support staff or natural supports every few months but is otherwise independent. The screener may select this answer if the applicant has recently become independent with a skill but may need some follow-up to ensure task completion. Since applicants may have support needs that may be irregular, using an average over the course of a few months is best practice.
• 1 to 4 times a month: The applicant requires, on average, assistance with tasks, emotional support, reinforcement, and symptom monitoring at least one time per month. Since applicants may have support needs that may be irregular, using an average over the course of a few months is best practice.
• More than one time per week: The applicant requires, on average, assistance with tasks, emotional support, reinforcement, and symptom monitoring more than once per week. Since applicants may have support needs that may be irregular, using an average over the course of a few months is best practice.

Impending discharge
When completing the screen with someone preparing for discharge from a mental health facility within the next few days, complete the screen based on how the person is expected to function at home. This looking ahead is a normal part of discharge planning. For example, although the facility administers medications now, mark on the screen if the person will need help with medication administration after they go home. It will take additional time and talking with the individual, facility staff, family, etc., to get the most accurate picture of the person’s needs at home after discharge. The screener must be able to envision the person at home.

3.2 Specific community living skills

Each community living skill or activity has its own description, which serves as the primary guide for screeners. The following sections provide additional instructions and examples of when the definition does or does not apply. These examples are not exhaustive or all-inclusive; they only supplement the definitions.

Please be sure to refer to the best practices for interviewing applicants section listed below for reference as the applicant is interviewed.

Best practices for interviewing applicants

• Follow the definitions outlined in this manual.
• Take cultural differences into account.
• Collect detailed information from multiple sources, including collateral contacts.
• Ask yourself:
  • What objective information do I have? What would a different screener, with a potentially different gender identity, culture, class, agency, etc., from myself, mark based on this information?
  • Does this answer reflect what might be in an initial care plan for this person?

Benefits/resource management
This skill relates to the need for assistance to plan for, access, and navigate benefits (Section 8, SSI, SSDI, Medicaid, Medicare, insurance, etc.). Needs related to money management are captured elsewhere in the screen.

Basic safety
This item is intended to focus narrowly on applicants who need help from others due to cognitive impairments caused by mental illness or substance use. It was not intended to cover all an applicant’s risky or unhealthy choices such as unsafe sex, drinking and driving, and poor health habits. Regarding substance use, consider the applicant’s cognitive functioning when not using drugs. Needs help from others means that if the applicant does not receive needed assistance, the applicant’s health and safety are at risk. If the person has in fact been doing something completely independently without any risk or harm, then it can be assumed that they don’t need help from others. Determining level of safety can be very subjective and vary among screeners. Please note any safety concerns in the notes section to explain the rationale for your choice.

Social or interpersonal skills
This section is meant to measure a person’s ability to socialize and interact with others, not their choice of whether to interact with others. Determining the level of social or interpersonal skills can be very subjective and vary among screeners so it is important to explain the rationale for the answer selection in the notes section.

This section is intended to measure how:

• The person cultivates and maintains adult social relationships.
• The person plans and carries out adult social or recreational activities.
• The person interacts with retail or service workers.
• The person behaves outside of their home.

As always, ask: “Would other screeners, given the same observations and information, check this box?”

Home hazards
This skill relates to the need for assistance to maintain a basic living environment to avoid disease, fire hazards or safety risks due to hoarding, odors noticeable from outside of the home, structural issues within the home, or concerns with the home’s utilities that may present other types of safety risks.

The question to ask here is: “Is the applicant’s housing environment adequate to avoid disease or danger?” Do not check this item if the applicant’s housekeeping has declined due to a mental illness or substance use disorder unless it has declined to the point of creating immediate danger or health hazards.

Note: Many times, if these problems are present, neighbors may complain and/or landlords may threaten eviction. However, since behaviors of neighbors and landlords can be arbitrary, the definition of this skill is based on an objective condition of the home, not the presence of complaints or eviction threats.

Money management
This skill identifies a need for assistance to manage finances for necessities (food, clothing, shelter), including the need for assistance to handle money, pay bills, and budget because of skill deficits or cognitive impairments due to the individual’s behavioral health needs.

Basic nutrition
This item measures the need for assistance to maintain an eating schedule and supply of unspoiled foods, obtain groceries, and/or to prepare or obtain routine meals safely due to cognitive impairment from their mental illness or substance use disorder. This skill does not cover transportation, which is captured elsewhere. 

Routine in this section is intended to mean average, not regularly scheduled. The person does not need to be able to make or prepare a full meal; they only need to be able to make or prepare simple meals such as a sandwich, cereal, and something heated on a stovetop or in a microwave.

General health maintenance
This item relates to needs for assistance to care for own health and to recognize symptoms. The person needs help from others because they are unable to self-manage current health conditions or health risks due to a cognitive impairment resulting from their mental illness or substance use disorder.

Unable to self-manage means the person:

• Is unable to recognize, manage, or respond to health problems or symptoms.
• Is unable to make or keep health care appointments.
• Does not know contributing factors and corrective actions.
• Has a history of failure to self-manage health resulting in multiple emergency room visits or hospitalizations (inpatient or outpatient).

This item does not include medication management (captured elsewhere) or transportation if a person arranges it on their own.

Managing psychiatric symptoms
This item relates to the need for assistance from others to manage mental health symptoms (such as hallucination, delusions, mania, depression, anxiety, etc.) Select yes in this section if the applicant:

• Is unable to reach out to mental health providers when symptoms are increasing.
• Is unable to recognize or respond to symptoms when they’re starting to prevent further symptom escalation and requires natural or paid supports to assist with symptom monitoring.

This item is limited to psychiatric symptoms. Substance use is addressed separately in the risk section of the screen.

Hygiene and grooming
This skill relates to needs for assistance to maintain basic hygiene and grooming due to cognitive impairment from their mental illness or substance use disorder without assistance or prompting from support people. Select yes in this section if the applicant requires assistance or prompting to maintain basic hygiene and grooming.

Taking medications
This skill relates to the need for assistance with taking medications. This section includes medications both for mental health and other health conditions. Competent adults have the right to refuse medications. See the guidance in the general health maintenance section for when the applicant chooses not to take medications versus when they need help from others because they are unable to self-manage current health conditions or health risks.

In this section, unable to self-manage means the applicant:

• Is unable to recognize and/or respond to problems related to their medications. 
• Has a history of failure to self-manage health resulting in multiple emergency room visits or hospitalizations (inpatient or outpatient).

The first question this section asks is if the applicant needs someone to administer their psychiatric medications through IM (intramuscular) injections. An individual needs assistance with administering their regular IM injections if they go to a clinic to receive the injections or have natural supports administer their IM injections. This question does not include other medications administered through IM injections such as vaccines or medications that are administered just under the skin such as insulin.

The second question applies to any medications prescribed by a medical doctor, an advanced practice nurse prescriber, or a physician’s assistant for a psychiatric or other medical condition. It does not include over-the-counter medications.

Assistance includes:

• Providing the applicant with medications.
• Watching the applicant take the medications to ensure they are taking them.
• Cueing the applicant to take medications (can include phone reminders).
• Preparing medications in med boxes or syringes.

The screen is intended to capture needs. Screeners should try to ascertain whether the individual is in fact independent with taking medications, regardless of what a service provider does when supporting a person.

The applicant may have a court order regarding treatment. Screeners should indicate medication assistance is needed if they feel support is needed for the applicant to follow the court order. The frequency marked on the screen should match the frequency that would be included in a treatment plan for the applicant.

Monitoring medication effects
This skill relates to the need for assistance monitoring effects and side effects of prescribed medications and applies to any medications prescribed by a medical doctor, advanced practice nurse prescriber, or physician’s assistant for a psychiatric or other medical condition. It does not include over-the-counter medications.

The applicant requires assistance if they can’t:

• Identify the effects, side effects, or non-effects of a medication.
• Report medication effects or new problems to a prescribing professional.
• Follow any medication or dose changes recommended by the prescriber.

Since prescription medications always involve a prescriber, the prescriber’s actions do not constitute assistance. Visits or contacts with a prescriber do not count. This item asks whether the applicant needs a third party as an intermediary between them and the prescriber.

When discussing prescribed psychiatric medications, there is a significant overlap between the monitoring for medication effects question and the managing psychiatric symptoms question elsewhere in the screen. When psychiatric medications are being adjusted to reduce psychiatric symptoms, screeners should check both managing psychiatric symptoms and monitoring for medication effects. Sometimes only one of the items is checked. An applicant may need assistance with monitoring medication effects but is able to manage their psychiatric symptoms independently. An applicant may need assistance managing their psychiatric symptoms from natural or paid supports but is able to notice medication issues or side effects.

Transportation
This skill relates to the ability to drive a regular or adapted vehicle, use public transportation, and/or arrange for transportation.

The answers include:

• Person drives.
• Person drives but there are serious safety concerns.
• Person cannot drive due to physical, psychiatric, or cognitive impairment. This includes no driver’s license due to medical problems (seizures, poor vision).
• Person does not drive due to other reasons (lost license, has no car).

Physical assistance
This skill relates to the need for assistance to physically accomplish the tasks listed. Check any options that the applicant requires assistance to complete due to physical limitations. Applicants may be eligible for long-term care services in addition to mental health and substance use disorder services. Select independent if the applicant doesn’t have physical limitations requiring assistance with any of the tasks listed. Limitations due to mental illness or cognitive limitations are covered in previous community living skills items.

Bathing
This refers to the ability to shower, bathe, or take sponge baths for the purpose of maintaining adequate hygiene. This also includes the ability to get in and out of a bathtub or shower stall, turn faucets on and off, regulate water temperature, and wash and dry fully.

Dressing
This refers to the ability to put on and take off clothing as necessary. This also refers to the ability to choose appropriate clothing for the weather and other situations. This also refers to the ability to put on prostheses, braces, and/or anti-embolism hose (“TED stockings”) with or without assistive devices. This also refers to fine motor coordination for buttons and zippers. Difficulties with a zipper or buttons at the back of a dress or blouse do not constitute a functional deficit.

Toileting
This refers to the ability to use the toilet, commode, bedpan, or urinal. This includes transferring on/off the toilet, cleansing of self, changing of pads, managing an ostomy or catheter, and adjusting clothes. Check this box if the applicant needs physical help from another person, or if they use a commode, elevated toilet seat, ostomy, urinary catheter, regular bowel program, or is incontinent more than monthly.

Mobility in home
This refers to the ability to move between locations in the individual’s living environment (defined as kitchen, living room, bathroom, and sleeping area). For purposes of the screen, this excludes basements, attics, and yards.

Transferring
This refers to the physical ability to move:

• From bed/chair to wheelchair, walker, or standing position.
• In and out of bed or usual sleeping place.
• Using assistive devices for transfers, excluding toileting transfers.
• With the physical help from another person or through the use of a mechanical lift, transfer board, or trapeze.